VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Friendship Assisted Living, Inc.
320 Hershberger Road
Roanoke, VA 24012
(540) 265-2244

Current Inspector: Holly Copeland (540) 309-5982

Inspection Date: April 19, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 32.1 Reported by persons other than physicians 63.2 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2 Facilities and Programs.. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report 22VAC40-80 THE LICENSE. 22VAC40-80 THE LICENSING PROCESS. 22VAC40-80 COMPLAINT INVESTIGATION. 22VAC40-80 SANCTIONS.

Comments:

On 4/19/2022 two inspectors conducted an annual monitoring visit (8:45 am to 4:27 pm). 84 residents were in care. Ten resident files, five staff files, and other documents were reviewed. A medication pass was observed, activities were observed, and a physical plant tour was done. An informal exit interview was held onsite the day of the inspection, and the facility was given an opportunity to provide additional documentation, if needed. A telephone exit interview was held on 4/22/2022.

Violations:

Standard #:	22VAC40-73-210-B
Description:	Based on review of staff records, the facility failed to ensure that a direct care staff person had at least 18 hours of training annually. EVIDENCE: 1. Staff 4 has documentation to support that 3.75 hours of training were obtained in the time period from 2/3/2021 through 2/2/2022.
Plan of Correction:	Staff member 4?s last day of employment is 4/28/2022. Going forward the Director of Nursing or designee will complete routine audits to ensure education/training requirements are met up to date. Staff members that are not current with education will be removed from the schedule until education requirements are met. Further disciplinary action will be taken for staff who continue to not meet education requirements.
Standard #:	22VAC40-73-270-4
Description:	Based on staff record review, the facility failed to ensure that a staff person had annual refresher training in methods of dealing with agitated or aggressive residents. EVIDENCE: 1. The record for staff 4 shows that there was no refresher training in methods of dealing with agitated or aggressive residents in the training year 2/3/2021 to 2/2/2022. Residents 2 and 5 have documentation in their charts showing they have agitated or aggressive behavior at times.
Plan of Correction:	Staff member 4?s last day of employment is 4/28/2022. Going forward the Director of Nursing or designee will complete routine audits to ensure education/training requirements are met up to date. Staff members that are not current with education will be removed from the schedule until education requirements are met. Further disciplinary action will be taken for staff who continue to not meet education requirements.
Standard #:	22VAC40-73-325-B
Description:	Based on resident record review and staff interview, the facility failed to ensure that the fall risk rating was reviewed and updated annually for each resident who meets the criteria for assisted living care. EVIDENCE: 1. The uniform assessment instrument (UAI) for resident 3, dated 11/20/2021, identified the resident as assisted living level of care. The record for resident 3 contained documentation that the last fall risk rating for the resident was conducted on 11/21/2020. Interview with staff 6 confirmed that this was the most recent fall risk rating for the resident.
Plan of Correction:	Education and reminders will be provided to staff members who are responsible for completing fall risk ratings; the Director of Nursing or designee will complete monthly audits to ensure all fall risk ratings are completed as required .
Standard #:	22VAC40-73-440-A
Description:	Based on resident record review and staff interview, the facility failed to complete the uniform assessment instrument (UAI) as required. EVIDENCE: 1. The UAI for resident 6, dated 08/22/2021, indicated that the resident is assisted living level of care; however, interview with staff determined that the resident is residential living level of care.
Plan of Correction:	Education to staff members responsible for completing the UAI and refresher course on UAI training will be completed within 30 days; Administrator or designee will review UAI?s for accuracy upon completion.
Standard #:	22VAC40-73-550-G
Description:	Based on staff record review, the facility failed to ensure that a staff person had annual training in resident rights and responsibilities. EVIDENCE: 1. The record for staff 4 has no documentation to support that annual training in residents rights and responsibilities was done during the training year of 2/3/2021 through 2/2/2022.
Plan of Correction:	Staff member 4?s last day of employment is 4/28/2022. Going forward the Director of Nursing or designee will complete routine audits to ensure education/training requirements are met up to date. Staff members that are not current with education will be removed from the schedule until education requirements are met. Further disciplinary action will be taken for staff who continue to not meet education requirements.
Standard #:	22VAC40-73-680-D
Description:	Based on observation and resident record review, the facility failed to ensure that a medication was administered in accordance with the physician's order. EVIDENCE: 1. Resident 12 has an order signed on 4/12/2022 for Vitamin D3 1.25 mg (50000 UT) (Cholecalciferol) to be given one time a day every Tuesday. This is not in the medication cart - resident 12 is being administered Vitamin D2 (Ergocalciferol) instead.
Plan of Correction:	The pharmacy was contacted upon discovery of error and was corrected on day of inspection; Going forward the pharmacy staff will double check all orders when filling medications prior to delivery; the staff member in charge during the shift medications are received will review each medication for accuracy prior to being stored on the medication cart.
Standard #:	22VAC40-73-680-M
Description:	Based on observation and resident record review, the facility failed to have a PRN medication available for a resident. EVIDENCE: 1. Resident 11 has an order signed 12/20/2021 for Tums, two tablets as needed for GI complaint. This medication is on the medication administration record (MAR), and the medication cart did not have them for this resident.
Plan of Correction:	Director of Nursing or designee will complete routine cart audits with comparison to MAR to ensure PRN (as needed) medications are available on the medication cart to be administered as ordered.
Standard #:	22VAC40-73-860-I
Description:	Based on observation, the facility failed to have cleaning supplies stored in a locked area. EVIDENCE: 1. The laundry was unlocked an unattended on a floor residents were using. The following cleaning products were stored in the laundry room: Comet, Shout, bleach, Downey Fabric Softener, and several brands of laundry detergent.
Plan of Correction:	The laundry will be locked at any time a staff member is not in attendance. A locked cabinet will also be added to the laundry room for all chemicals to be stored in. The Director of Housekeeping will be responsible for assuring that chemicals are no longer unsecured in the laundry.